Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and Health Survey

Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and... Abstract Aim The aim of this study is to examine the prevalence of bottle feeding (BF) among children aged 0–23 months and factors associated with BF in Namibia. Methods Data from Namibia 2013 Demographic Health Survey were used for the study. The study covered last-born alive children aged 0–23 months, making up 1926 mother–baby pairs. Chi-square tests and binary logistic regression were used to test for association between BF and related factors. Results Prevalence of BF in Namibia was 35.7%. In the multivariate analysis, the following factors were significantly associated with increased risk of BF: working mothers, hospital delivery, increasing child age, higher mother’s educational status, higher wealth quintile and urban residence. Conclusion To achieve a substantial decrease in bottle usage rate in Namibia, breastfeeding promotion programmes should target all mothers but especially those at risk of BF highlighted in the study. bottle-feeding, Namibia, breastfeeding, usage INTRODUCTION Breastfeeding is beneficial for mother–baby pairs, families and the society, as it has immunological, nutritional, developmental, socio-economic and environmental benefits [1–5]. Optimal breastfeeding includes early initiation of breastfeeding, i.e within 1 h of birth, exclusive breastfeeding for the first 6 months of life and continued breastfeeding for up to 2 years or beyond with appropriate complementary feeding beginning at 6 months [6]. In Namibia, not all children are exclusively breastfed in the first 6 months of life, with only about 49% of children aged <6 months being exclusively breastfed [7]. After 6 months of age, it is recommended that any liquids given to the child should be fed by cup rather than by bottle, avoiding the use of bottle with nipple [8]. However, over the past few years, an increase in bottle feeding (BF) has been observed in developing countries [9]. Feeding a child using a bottle with a nipple is not encouraged because it endangers the child’s health and survival through contamination, and interferes with breastfeeding establishment. Also, BF is associated with a greater risk of short pregnancy interval [10]. The adverse effects of BF are profound in developing countries owing to lack of access to clean water as well as unhygienic surroundings [11]. In addition, the prevalence of low-quality and unsuitable bottles and teats in these countries further aggravate the situation [12]. Existing literature indicates that the following factors affect BF: mother’s working status, maternal education, institutional delivery, wealth index, child age, parity and aggressive marketing and promotion of breast-milk substitutes [9, 12–14]. In Namibia, there is a paucity of studies based on nationally representative samples examining the determinant of BF, and this research fills this gap. The study purpose is twofold. First, to determine the prevalence of BF in Namibia, and second, to examine factors associated with BF in the aforementioned country. An understanding of the factors influencing BF in Namibia will aid the country’s policy makers in framing policies and programmes that would decrease BF, which in turn will contribute in reducing child morbidity and mortality. MATERIALS AND METHODS Sample The study used data from the 2013 Demographic Health Survey (DHS) conducted in Namibia. All women aged 15–49 years who were either permanent residents of the households or women present in the households on the night before the survey were eligible to be interviewed during the survey. Further details of the sampling and data collection method can be found in the DHS manual [7]. Analysis for this study was restricted to last-born children who were alive and aged <2 years at the time of the survey. The total sample size was 1926 mother–baby pairs. After accounting for sample weights, this corresponded to a sample size of 1815 mother–baby pair. Operational definition(s) In the DHS woman's questionnaire, mothers were asked, ‘Did (child name) drink anything from a bottle with a nipple yesterday or last night?’ [7]. The outcome variable ‘BF’ was defined as drinking anything from a bottle with nipple yesterday or past night and was expressed as a dichotomous variable with category 1 for children who drank anything from a bottle with nipple yesterday or past night and Category 0 for children who did not. The explanatory variables were chosen based on previous studies [9, 12–14] and included mother’s age, mother’s education, mother’s occupation, place of residence, birth rank, delivery type and place, sex of child, postnatal check within 2 months of birth, child age and wealth index, which was categorized into lowest (poorest), second (poorer), middle, fourth (richer) and highest (richest) wealth quintile; the index was constructed using household asset data via a principal components analysis. Statistical analysis Sample characteristics are given as unweighted case numbers and percentages, whereas BF distribution by different explanatory variables were reported as weighted percentages based on women’s individual weights. Chi-square tests were performed to evaluate the association of the explanatory variables with BF, and variables significant at the 0.25 level were included in the multivariate analysis and assessed by binary logistic regression. Adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were reported. The multivariate analysis accounted for the sample design and sample weight using Statistical Package for Social Sciences (SPSS) complex sample analysis method (SPSS version 24). Ethics The survey was reviewed and approved by the inner city fund (ICF) institutional review board, which offered technical support for the survey and by the National Ethics Committee of Namibia. Permission to use and analyse the data set was obtained by registering the study on the Demographic and Health Survey (DHS) website. RESULTS Socio-demographic characteristics of study participants Table 1 shows the socio-demographic characteristics of the study participants. The highest proportion of mothers belonged to the age group 20–34 years (69.9%), and a greater percentage of mothers resided in rural areas (Table 1). Table 1 Socio-demographic characteristics of study participants Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Note.aUnweighted. Table 1 Socio-demographic characteristics of study participants Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Note.aUnweighted. The overall prevalence of BF in Namibia was 35.7%. According to regions, the highest prevalence of BF was observed in Khomas (56.8%), Erongo (56.1%) and Karas (56.1%), while the lowest prevalence of BF was reported in Ohangwena (19.3%) (Fig. 1). Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Unadjusted associations with BF Table 2 shows the unadjusted association of explanatory variables with BF. BF was significantly higher among the following categories: mothers with secondary and above educational status, working mothers, mothers belonging to the highest wealth quintile, urban mothers, mothers with second to third birth order, mothers with health facility-caesarean delivery, children with post-natal check within 2 months of birth and children in the age group 6–11 months (Table 2). Table 2 Rates of BF among children aged 0–23 months Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Note. aWeighted. Table 2 Rates of BF among children aged 0–23 months Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Note. aWeighted. Multivariate analysis Table 3 shows the adjusted associations between BF and explanatory variables. The odds of BF was significantly higher for mothers with secondary and above educational status as compared with mothers with primary and below educational status. In addition, mothers who were working had 51% higher odds of BF as compared with mothers who were not working. When compared with the lowest wealth quintile, mothers who belonged to higher wealth quantile had higher odds of BF. Furthermore, mothers who resided in urban areas had 67% higher odds of BF as compared with mothers who resided in rural areas. Women who had health facility-vaginal delivery or health facility-caesarean delivery were more likely to bottle feed their children as compared with women who delivered at home. According to the study findings, children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. Table 3 Factors associated with BF in children aged 0–23 months Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. Table 3 Factors associated with BF in children aged 0–23 months Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. DISCUSSION Namibia has an overall BF prevalence of 35.7% among children aged 0–23 months. The prevalence of BF showed variability among regions, with region like Khomas (56.8%) reporting higher prevalence of BF and region like Ohangwena (19.3%) recording lower prevalence. The overall prevalence of BF among children aged 0–23 months in Namibia was much higher than what was observed in Tanzania and Pakistan among children aged 0–23 months. In Tanzania, the authors reported a prevalence of 3.2% for BF, while in Pakistan, Hazir et al. [15, 16] reported a BF prevalence of 31.2%. The difference in BF prevalence between Namibia and the aforementioned countries might be attributed to country’s difference in socio-demographic and economic status and such differences at individual, household and community levels may play a role. The reported prevalence of BF in Namibia suggests the need for policy makers and public health practitioners in Namibia to focus more on achieving a considerable decrease in the prevalence of BF in their country. In this study, mothers working status influenced BF. Working mothers were more likely to bottle feed as compared with their non-working counterpart. This finding is in consonance with studies done in Bangladesh and Ethiopia [17, 18] and reflect the need for policy makers to consider improving maternity leave situation of working mothers. There is also a need to ensure that working mothers are provided breastfeeding breaks and breastfeeding spaces [19]. It is generally assumed that mothers who deliver at health facilities are more likely to get information on breastfeeding at the health facility; however, in the current study, mothers who delivered in a hospital had higher risk of BF as compared with mothers who delivered at home. This result is in conformity with a study done by Hazir et al. [16] and indicates the need for a reassessment of baby-friendly hospital management method in Namibia. In the literature, there are studies indicating that marketing of infant formula with a focus on the health system might contribute to the increase in bottle usage among mothers who had institutional delivery [20–22]. Associations have been found between child age and the use of artificial nipple [23, 24]. In the current study, older children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. The increase in the use of BF as the child age progress might be explained by the fact that bottle use is associated with water, tea and processed milk intake, which are commonly given as the child age progress [24]. Another factor that was associated with bottle usage rate was mother’s educational status. BF was significantly higher among mothers with higher educational status; this finding is in consonance with studies done by Hazir et al. [16] and Boerme et al. [9] that showed that increasing level of education was significantly associated with higher levels of bottle use. The study finding with regards mother’s educational status and BF reflect the fact that higher mother’s educational status does not necessarily mean increased awareness and understanding of the advantages of breastfeeding. Wealth index was another significant predictor of BF. Mothers belonging to higher wealth quintiles were more likely to bottle feed than mothers in the lowest wealth quintiles; this is in line with previous studies that found higher socio-economic status to be associated with BF [16, 17]. This finding may be explained by the fact that mothers belonging to the higher wealth quintile may have easy access to expensive breastfeeding alternatives, which might indirectly influence their choice to bottle feed. In public health literature, there are studies indicating an association between breastfeeding practices and place of residence [25–27]. In the current study, urban mothers were more likely to bottle feed as compared with their rural counterpart. This finding is consistent with previous studies that have shown urban mothers to be at a greater risk of BF as compared with rural mothers [9, 16]. A plausible explanation for this result could be that most urban mothers were more likely to be from families with higher socio-economic status as compared with their rural counterparts and that may have facilitated their access to breast-milk substitutes and information on breast-milk substitute; furthermore, most urban mothers are likely to have paid employment and the pressure to return to work after maternity leave might result in bottle usage [15, 28]. This study is not without some limitations. The data were based on a cross-sectional study as such is subject to recall limitation; in addition, caution must be exercised in making causal influence of the identified determinants of BF. Culturally, in Namibia, families are organized along kinship lines, with children being cared for by multiple members of the extended family. Future studies looking at factors such as family structures, cultural practice and ethnicity will help in enriching the knowledge on BF in Namibia. The study strength lies in the nationally representative sample and the adjustments made for sampling design during the analysis. CONCLUSION To decrease BF prevalence in Namibia, interventions should include breastfeeding promotion through Information, Education and Communication targeting all mothers, but most especially mothers belonging to at-risk subgroups of BF highlighted in this study. Also, part of the interventions should include training of health workers on Infant and Young Child Feeding (IYCF) counselling, promotion of safe and healthy IYCF practices and proper enforcement of the International Code of Marketing of Breast-milk Substitutes. ACKNOWLEDGEMENTS The author would like to acknowledge Measure DHS for making available the 2013 NDHS data set for this study. REFERENCES 1 Anatolitou F. Human milk benefits and breastfeeding. J Pediatr Neonat Individual Med  2012; 1: 11– 18. 2 Sankar MJ, Sinha B, Chowdhury R, et al.   Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr  2015; 104: 3– 13. http://dx.doi.org/10.1111/apa.13147 Google Scholar CrossRef Search ADS PubMed  3 Ip S, Chung M, Raman G, et al.   Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess  2007; 153: 1– 186. 4 Victora CG, Horta BL, de Mola CL, et al.   Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health  2015; 3: e199– 205. Google Scholar CrossRef Search ADS PubMed  5 Chowdhury R, Sinha B, Sankar MJ, et al.   Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr Suppl  2015; 104: 96– 113. http://dx.doi.org/10.1111/apa.13102 Google Scholar CrossRef Search ADS   6 Victora CG, Bahl R, Barros AJD; for The Lancet Breastfeeding Series Group, et al.   Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet  2016; 387: 475– 90. http://dx.doi.org/10.1016/S0140-6736(15)01024-7 Google Scholar CrossRef Search ADS PubMed  7 The Namibia Ministry of Health and Social Services (MoHSS) and ICF International. The Namibia Demographic and Health Survey 2013 . Windhoek, Namibia; Rockville, MD: The Namibia Ministry of Health and Social Services (MoHSS) and ICF International, 2014. 8 WHO. Infant and young child feeding: a tool for assessing national practices, policies and programmes . Geneva, Switzerland: WHO, 2003. 9 Boerma JT, Rutstein SO, Sommerfelt AE, et al.   Bottle use for infant feeding in developing countries: data from the demographic and health surveys: has the bottle battle been lost? J Trop Pediatr  1991; 37: 116– 20. Google Scholar CrossRef Search ADS PubMed  10 Huffman SL, Lamphere BB. Breastfeeding performance and child survival. In: Mosley WH, Chen LC (eds). Child Survival: Strategies for Research . Cambridge: Cambridge University Press, 1984, 93– 116. 11 Jason JM, Niebugr P, Marks JS. Mortality and infectious disease associated with infant feeding practices in developing countries. Pediatrics  1984; 74: 702– 27. Google Scholar PubMed  12 Shamim S, Jamalvi SW, Naz F. Determinants of bottle use amongst economically disadvantaged mothers. J Ayub Med Coll Abbottabad  2006; 18: 48– 51. Google Scholar PubMed  13 Buccini Gdos S, Benício MH, Venancio S. Determinants of using pacifier and bottle feeding. Rev Saude Publica  2014; 48: 571– 82. Google Scholar CrossRef Search ADS PubMed  14 Okeyo NO, Konyole SO, Okeyo LA, et al.   Characteristics of caregivers and households practicing bottle-feeding in Kisumu east district. African Journal of Food, Agriculture, Nutrition and Development  2012; 12: 6868– 79. 15 Victor R, Baines SK, Agho KE, et al.   Determinants of breastfeeding indicators among children less than 24 months of age in Tanzania: a secondary analysis of the 2010 Tanzania Demographic and Health Survey. BMJ Open  2013; 3: e001529. doi: 10.1136/bmjopen-2012-001529. Google Scholar CrossRef Search ADS PubMed  16 Hazir T, Akram DS, Nisar YB, et al.   Determinants of suboptimal breast-feeding practices in Pakistan. Public Health Nutr  2013; 16: 659– 72. http://dx.doi.org/10.1017/S1368980012002935 Google Scholar CrossRef Search ADS PubMed  17 Mihrshahi S, Kabir I, Roy SK, et al.   Determinants of infant and young child feeding practices in Bangladesh: secondary data analysis of Demographic and Health Survey 2004. Food Nutr Bull  2010; 31: 295– 313. http://dx.doi.org/10.1177/156482651003100220 Google Scholar CrossRef Search ADS PubMed  18 Gebriel A. Determinant of weaning practices. Ethiop J Health Dev  2000; 14: 183– 9. http://dx.doi.org/10.4314/ejhd.v14i2.9919 Google Scholar CrossRef Search ADS   19 UNICEF. Improving breastfeeding, complementary foods and feeding practices. https://www.unicef.org/nutrition/index_breastfeeding.html (26 June 2017, date last accessed). 20 Pries AM, Huffman SL, Mengkheang K, et al.   Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding. Maternal & Child Nutrition  2016; 12: 38– 51. http://dx.doi.org/10.1111/mcn.12271 Google Scholar CrossRef Search ADS PubMed  21 Hanif R, Khalil E, Sheikh A, et al.   Knowledge about breastfeeding in accordance with the national policy among doctors, paramedics and mothers in baby-friendly hospitals. J Pak Med Assoc  2008; 60: 881– 6. 22 Winikoff B, Laukaran VH. Breastfeeding and bottle feeding controversies in the developing World: evidence from a study in four countries. Soc Sci Med  1989; 29: 859– 68. http://dx.doi.org/10.1016/0277-9536(89)90085-3 Google Scholar CrossRef Search ADS PubMed  23 Aarts C, Hornell A, Kylberg E, et al.   Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics  1999; 104: e50. Google Scholar CrossRef Search ADS PubMed  24 Victora CG, Behague DP, Barros FC, et al.   Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics  1997; 99: 445– 53. Google Scholar CrossRef Search ADS PubMed  25 Roberts GJ, Cleaton-Jones PE, et al.   Breast and bottle feeding in rural and urban South African children. J Hum Nutr Diet  1995; 8: 255– 63. http://dx.doi.org/10.1111/j.1365-277X.1995.tb00319.x Google Scholar CrossRef Search ADS   26 Dev K, Agarwal KN, Tewari IC, et al.   Breast feeding practices in urban slum and rural areas of varanasi. J Trop Pediatr  1982; 28: 89– 92. http://dx.doi.org/10.1093/tropej/28.2.89 Google Scholar CrossRef Search ADS PubMed  27 Senarath U, Siriwardena I, Godakandage SSP, et al.   Determinants of breastfeeding practices: an analysis of the Sri Lanka Demographic and Health Survey 2006–2007. Matern Child Nutr  2012; 8: 315– 29. http://dx.doi.org/10.1111/j.1740-8709.2011.00321.x Google Scholar CrossRef Search ADS PubMed  28 Senarath U, Dibley MJ, Agho KE. Factors associated with nonexclusive breastfeeding in 5 East and Southeast Asian countries: a multilevel analysis. J Hum Lact  2010; 26: 248. http://dx.doi.org/10.1177/0890334409357562 Google Scholar CrossRef Search ADS PubMed  © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

Factors Associated with Bottle Feeding in Namibia: Findings from Namibia 2013 Demographic and Health Survey

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Abstract

Abstract Aim The aim of this study is to examine the prevalence of bottle feeding (BF) among children aged 0–23 months and factors associated with BF in Namibia. Methods Data from Namibia 2013 Demographic Health Survey were used for the study. The study covered last-born alive children aged 0–23 months, making up 1926 mother–baby pairs. Chi-square tests and binary logistic regression were used to test for association between BF and related factors. Results Prevalence of BF in Namibia was 35.7%. In the multivariate analysis, the following factors were significantly associated with increased risk of BF: working mothers, hospital delivery, increasing child age, higher mother’s educational status, higher wealth quintile and urban residence. Conclusion To achieve a substantial decrease in bottle usage rate in Namibia, breastfeeding promotion programmes should target all mothers but especially those at risk of BF highlighted in the study. bottle-feeding, Namibia, breastfeeding, usage INTRODUCTION Breastfeeding is beneficial for mother–baby pairs, families and the society, as it has immunological, nutritional, developmental, socio-economic and environmental benefits [1–5]. Optimal breastfeeding includes early initiation of breastfeeding, i.e within 1 h of birth, exclusive breastfeeding for the first 6 months of life and continued breastfeeding for up to 2 years or beyond with appropriate complementary feeding beginning at 6 months [6]. In Namibia, not all children are exclusively breastfed in the first 6 months of life, with only about 49% of children aged <6 months being exclusively breastfed [7]. After 6 months of age, it is recommended that any liquids given to the child should be fed by cup rather than by bottle, avoiding the use of bottle with nipple [8]. However, over the past few years, an increase in bottle feeding (BF) has been observed in developing countries [9]. Feeding a child using a bottle with a nipple is not encouraged because it endangers the child’s health and survival through contamination, and interferes with breastfeeding establishment. Also, BF is associated with a greater risk of short pregnancy interval [10]. The adverse effects of BF are profound in developing countries owing to lack of access to clean water as well as unhygienic surroundings [11]. In addition, the prevalence of low-quality and unsuitable bottles and teats in these countries further aggravate the situation [12]. Existing literature indicates that the following factors affect BF: mother’s working status, maternal education, institutional delivery, wealth index, child age, parity and aggressive marketing and promotion of breast-milk substitutes [9, 12–14]. In Namibia, there is a paucity of studies based on nationally representative samples examining the determinant of BF, and this research fills this gap. The study purpose is twofold. First, to determine the prevalence of BF in Namibia, and second, to examine factors associated with BF in the aforementioned country. An understanding of the factors influencing BF in Namibia will aid the country’s policy makers in framing policies and programmes that would decrease BF, which in turn will contribute in reducing child morbidity and mortality. MATERIALS AND METHODS Sample The study used data from the 2013 Demographic Health Survey (DHS) conducted in Namibia. All women aged 15–49 years who were either permanent residents of the households or women present in the households on the night before the survey were eligible to be interviewed during the survey. Further details of the sampling and data collection method can be found in the DHS manual [7]. Analysis for this study was restricted to last-born children who were alive and aged <2 years at the time of the survey. The total sample size was 1926 mother–baby pairs. After accounting for sample weights, this corresponded to a sample size of 1815 mother–baby pair. Operational definition(s) In the DHS woman's questionnaire, mothers were asked, ‘Did (child name) drink anything from a bottle with a nipple yesterday or last night?’ [7]. The outcome variable ‘BF’ was defined as drinking anything from a bottle with nipple yesterday or past night and was expressed as a dichotomous variable with category 1 for children who drank anything from a bottle with nipple yesterday or past night and Category 0 for children who did not. The explanatory variables were chosen based on previous studies [9, 12–14] and included mother’s age, mother’s education, mother’s occupation, place of residence, birth rank, delivery type and place, sex of child, postnatal check within 2 months of birth, child age and wealth index, which was categorized into lowest (poorest), second (poorer), middle, fourth (richer) and highest (richest) wealth quintile; the index was constructed using household asset data via a principal components analysis. Statistical analysis Sample characteristics are given as unweighted case numbers and percentages, whereas BF distribution by different explanatory variables were reported as weighted percentages based on women’s individual weights. Chi-square tests were performed to evaluate the association of the explanatory variables with BF, and variables significant at the 0.25 level were included in the multivariate analysis and assessed by binary logistic regression. Adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were reported. The multivariate analysis accounted for the sample design and sample weight using Statistical Package for Social Sciences (SPSS) complex sample analysis method (SPSS version 24). Ethics The survey was reviewed and approved by the inner city fund (ICF) institutional review board, which offered technical support for the survey and by the National Ethics Committee of Namibia. Permission to use and analyse the data set was obtained by registering the study on the Demographic and Health Survey (DHS) website. RESULTS Socio-demographic characteristics of study participants Table 1 shows the socio-demographic characteristics of the study participants. The highest proportion of mothers belonged to the age group 20–34 years (69.9%), and a greater percentage of mothers resided in rural areas (Table 1). Table 1 Socio-demographic characteristics of study participants Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Note.aUnweighted. Table 1 Socio-demographic characteristics of study participants Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Characteristics  Na  %a  Mother’s age (years)       15–19  212  11.0   20–34  1347  69.9   35 and above  367  19.1  Marital status       Never in a union/formerly in union/living with a man  1044  54.2   Currently in union/living with a man  882  45.8  Mother’s education       Primary and below  598  31.0   Secondary and above  1328  69.0  Mother’s occupation       Not working  1144  59.5   Working  780  40.5  Wealth quintile       Lowest  410  21.3   Second  444  23.1   Middle  437  22.7   Fourth  383  19.9   Highest  252  13.1  Place of residence       Urban  840  43.6   Rural  1086  56.4  Birth rank       1st birth rank  592  30.7   2nd–3rd birth rank  807  41.9   4th birth rank  527  27.4  Delivery type and place       Home  262  13.7   Health facility—vaginal delivery  1370  71.4   Health facility—caesarean section  287  15.0  Sex of child       Male  928  48.2   Female  998  51.8  Baby received postnatal check within 2 months of birth       Yes  965  50.3   No  955  49.7  Child’s age (months)       0–5  527  27.4   6–11  503  26.1   12–23  896  46.5  Note.aUnweighted. The overall prevalence of BF in Namibia was 35.7%. According to regions, the highest prevalence of BF was observed in Khomas (56.8%), Erongo (56.1%) and Karas (56.1%), while the lowest prevalence of BF was reported in Ohangwena (19.3%) (Fig. 1). Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Fig. 1. View largeDownload slide Regional BF prevalence in children aged 0–23 months in Namibia. Unadjusted associations with BF Table 2 shows the unadjusted association of explanatory variables with BF. BF was significantly higher among the following categories: mothers with secondary and above educational status, working mothers, mothers belonging to the highest wealth quintile, urban mothers, mothers with second to third birth order, mothers with health facility-caesarean delivery, children with post-natal check within 2 months of birth and children in the age group 6–11 months (Table 2). Table 2 Rates of BF among children aged 0–23 months Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Note. aWeighted. Table 2 Rates of BF among children aged 0–23 months Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Characteristics  Had BF   p value  na  %a  Mother’s age (years)         15–19  60  30.5  0.147   20–34  458  35.8     35 and above  131  38.9    Marital status         Never in a union/formerly in union/living with a man  349  34.8  0.352   Currently in union/living with a man  299  36.9    Mother’s education         Primary and below  109  21.3  <0.001   Secondary and above  539  41.4    Mother’s occupation         Not working  296  28.3  <0.001   Working  352  46.0    Wealth quintile         Lowest  71  18.1  <0.001   Second  129  30.6     Middle  136  34.6     Fourth  153  43.5     Highest  158  62.5    Place of residence         Urban  408  48.9  <0.001   Rural  241  24.6    Birth rank         1st birth rank  217  37.9  0.002   2nd–3rd birth rank  296  38.2     ≥4th birth rank  135  28.8    Delivery type and place         Home  34  16.1  <0.001   Health facility—vaginal delivery  463  35.4     Health facility—caesarean delivery  150  51.7    Sex of child         Male  317  36.1  0.742   Female  331  35.4    Baby received postnatal check within 2 months of birth         Yes  359  38.5  0.012   No  288  32.8    Child’s age (months)         0–5  126  25.9  <0.001   6–11  250  50.8     12–23  272  32.5    Note. aWeighted. Multivariate analysis Table 3 shows the adjusted associations between BF and explanatory variables. The odds of BF was significantly higher for mothers with secondary and above educational status as compared with mothers with primary and below educational status. In addition, mothers who were working had 51% higher odds of BF as compared with mothers who were not working. When compared with the lowest wealth quintile, mothers who belonged to higher wealth quantile had higher odds of BF. Furthermore, mothers who resided in urban areas had 67% higher odds of BF as compared with mothers who resided in rural areas. Women who had health facility-vaginal delivery or health facility-caesarean delivery were more likely to bottle feed their children as compared with women who delivered at home. According to the study findings, children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. Table 3 Factors associated with BF in children aged 0–23 months Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. Table 3 Factors associated with BF in children aged 0–23 months Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Characteristics  OR (95% CI)  p value  AOR (95% CI)  p value  Mother’s age (years)           15–19  Ref    Ref     20–34  1.28 (0.88–1.86)  0.192  1.06 (0.70–1.60)  0.792   35 and above  1.46 (0.93–2.27)  0.098  1.43 (0.86–2.40)  0.169  Mother’s education           Primary and below  Ref    Ref     Secondary and above  2.62 (1.93–3.55)  <0.001  1.54 (1.12–2.11)  0.007  Mother’s occupation           Not working  Ref    Ref     Working  2.15 (1.73–2.68)  <0.001  1.51 (1.19–1.93)  0.001  Wealth quintile           Lowest  Ref    Ref     Second  1.99 (1.42–2.79)  <0.001  1.46 (1.01–2.11)  0.043   Middle  2.39 (1.71–3.35)  <0.001  1.50 (1.04–2.17)  0.031   Fourth  3.46 (2.45–4.88)  <0.001  1.83 (1.23–2.72)  0.003   Highest  7.51 (4.99–11.30)  <0.001  2.85 (1.76–4.63)  <0.001  Place of residence           Urban  2.93 (2.30–3.73)  <0.001  1.67 (1.26–2.22)  <0.001   Rural  Ref    Ref    Birth rank           1st birth rank  1.51 (1.12–2.03)  0.006  1.16 (0.79–1.70)  0.460   2nd–3rd birth rank  1.53 (1.13–2.06)  0.005  1.14 (0.80–1.61)  0.476   ≥4th birth rank  Ref    Ref    Delivery place and type           Home  Ref    Ref     Health facility—vaginal delivery  2.87 (1.93–4.25)  <0.001  1.66 (1.07–2.57)  0.023   Health facility—caesarean delivery  5.60 (3.51–8.94)  <0.001  2.30 (1.37–3.88)  0.002  Baby received postnatal check within 2 months of birth           No  Ref    Ref     Yes  1.28 (1.02–1.62)  0.038  1.15 (0.91–1.44)  0.239  Child’s age (months)           0–5  Ref    Ref     6–11  2.97 (2.19–4.03)  <0.001  3.32 (2.37–4.63)  <0.001   12–23  1.38 (1.06–1.80)  0.016  1.26 (0.94–1.70)  0.129  Note. Ref = reference category; OR = odds ratio; AOR = adjusted odds ratio. DISCUSSION Namibia has an overall BF prevalence of 35.7% among children aged 0–23 months. The prevalence of BF showed variability among regions, with region like Khomas (56.8%) reporting higher prevalence of BF and region like Ohangwena (19.3%) recording lower prevalence. The overall prevalence of BF among children aged 0–23 months in Namibia was much higher than what was observed in Tanzania and Pakistan among children aged 0–23 months. In Tanzania, the authors reported a prevalence of 3.2% for BF, while in Pakistan, Hazir et al. [15, 16] reported a BF prevalence of 31.2%. The difference in BF prevalence between Namibia and the aforementioned countries might be attributed to country’s difference in socio-demographic and economic status and such differences at individual, household and community levels may play a role. The reported prevalence of BF in Namibia suggests the need for policy makers and public health practitioners in Namibia to focus more on achieving a considerable decrease in the prevalence of BF in their country. In this study, mothers working status influenced BF. Working mothers were more likely to bottle feed as compared with their non-working counterpart. This finding is in consonance with studies done in Bangladesh and Ethiopia [17, 18] and reflect the need for policy makers to consider improving maternity leave situation of working mothers. There is also a need to ensure that working mothers are provided breastfeeding breaks and breastfeeding spaces [19]. It is generally assumed that mothers who deliver at health facilities are more likely to get information on breastfeeding at the health facility; however, in the current study, mothers who delivered in a hospital had higher risk of BF as compared with mothers who delivered at home. This result is in conformity with a study done by Hazir et al. [16] and indicates the need for a reassessment of baby-friendly hospital management method in Namibia. In the literature, there are studies indicating that marketing of infant formula with a focus on the health system might contribute to the increase in bottle usage among mothers who had institutional delivery [20–22]. Associations have been found between child age and the use of artificial nipple [23, 24]. In the current study, older children in the age group 6–11 months were more likely to be bottle fed as compared with children in the age group 0–5 months. The increase in the use of BF as the child age progress might be explained by the fact that bottle use is associated with water, tea and processed milk intake, which are commonly given as the child age progress [24]. Another factor that was associated with bottle usage rate was mother’s educational status. BF was significantly higher among mothers with higher educational status; this finding is in consonance with studies done by Hazir et al. [16] and Boerme et al. [9] that showed that increasing level of education was significantly associated with higher levels of bottle use. The study finding with regards mother’s educational status and BF reflect the fact that higher mother’s educational status does not necessarily mean increased awareness and understanding of the advantages of breastfeeding. Wealth index was another significant predictor of BF. Mothers belonging to higher wealth quintiles were more likely to bottle feed than mothers in the lowest wealth quintiles; this is in line with previous studies that found higher socio-economic status to be associated with BF [16, 17]. This finding may be explained by the fact that mothers belonging to the higher wealth quintile may have easy access to expensive breastfeeding alternatives, which might indirectly influence their choice to bottle feed. In public health literature, there are studies indicating an association between breastfeeding practices and place of residence [25–27]. In the current study, urban mothers were more likely to bottle feed as compared with their rural counterpart. This finding is consistent with previous studies that have shown urban mothers to be at a greater risk of BF as compared with rural mothers [9, 16]. A plausible explanation for this result could be that most urban mothers were more likely to be from families with higher socio-economic status as compared with their rural counterparts and that may have facilitated their access to breast-milk substitutes and information on breast-milk substitute; furthermore, most urban mothers are likely to have paid employment and the pressure to return to work after maternity leave might result in bottle usage [15, 28]. This study is not without some limitations. The data were based on a cross-sectional study as such is subject to recall limitation; in addition, caution must be exercised in making causal influence of the identified determinants of BF. Culturally, in Namibia, families are organized along kinship lines, with children being cared for by multiple members of the extended family. Future studies looking at factors such as family structures, cultural practice and ethnicity will help in enriching the knowledge on BF in Namibia. The study strength lies in the nationally representative sample and the adjustments made for sampling design during the analysis. CONCLUSION To decrease BF prevalence in Namibia, interventions should include breastfeeding promotion through Information, Education and Communication targeting all mothers, but most especially mothers belonging to at-risk subgroups of BF highlighted in this study. Also, part of the interventions should include training of health workers on Infant and Young Child Feeding (IYCF) counselling, promotion of safe and healthy IYCF practices and proper enforcement of the International Code of Marketing of Breast-milk Substitutes. ACKNOWLEDGEMENTS The author would like to acknowledge Measure DHS for making available the 2013 NDHS data set for this study. REFERENCES 1 Anatolitou F. Human milk benefits and breastfeeding. 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Journal of Tropical PediatricsOxford University Press

Published: Nov 30, 2017

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